White spots that appear on the heel when pressure is applied are a specific, transient phenomenon that often causes concern but is typically harmless. The medical term for this presentation is Piezogenic Papules, a name derived from the Greek word piezin, meaning “to press.” This condition is purely a response to mechanical force, with the spots disappearing immediately once the pressure is removed.
Identifying Piezogenic Papules
Piezogenic papules are small, soft lumps that develop on the heel when an individual is standing or bearing weight. They generally present as skin-colored, white, or slightly yellowish nodules, ranging in size from a few millimeters up to a centimeter. These lesions most frequently appear along the medial and lateral borders of the heel, though they can occur anywhere on the weight-bearing surface.
The definitive characteristic of these spots is their complete disappearance upon the removal of pressure, such as when the foot is elevated. While they are usually found bilaterally, appearing on both heels, most people who have them do not experience any pain or discomfort.
Painful papules, while less common, are sometimes associated with a lack of blood supply to the tissue caused by the compression. The diagnosis is based entirely on this visual change under pressure, meaning no laboratory tests or imaging studies are typically necessary.
The Underlying Mechanism of Spot Formation
The appearance of piezogenic papules is a physical manifestation of a structural change in the foot’s padding under force. The heel contains a thick layer of subcutaneous fat, which is normally held in place by strong bands of collagen and connective tissue called fibrous septa. The mechanism involves the herniation, or protrusion, of this subcutaneous fat through small defects or areas of weakness in these fibrous septa. This process is not a result of inflammation but rather a mechanical effect on the connective tissue.
Several factors can contribute to this weakness in the fibrous septa, increasing the likelihood of fat herniation. Increased body weight places excessive stress on the heels, which is a common risk factor. Activities that involve repetitive or prolonged pressure, such as long-distance running or occupations requiring long periods of standing, can also contribute. A genetic predisposition or underlying connective tissue disorders, like Ehlers-Danlos syndrome, may also be a factor in some cases.
Management and When to Consult a Specialist
For the vast majority of individuals, piezogenic papules are asymptomatic and require no medical treatment. If the papules are not causing pain, the best approach is reassurance and conservative management. Simple lifestyle adjustments can often alleviate discomfort in the small percentage of cases where pain is present.
Conservative strategies include wearing well-cushioned, supportive footwear to better distribute pressure across the foot. Custom orthotic shoe inserts or foam rubber heel cups can provide additional padding and support to reduce localized pressure on the heel. Maintaining a healthy weight is also helpful, as it reduces the overall load on the feet, minimizing the force that causes the fat herniation.
If the papules become persistently painful, limit the ability to walk normally, or interfere with daily activities, consult a healthcare specialist. A podiatrist or dermatologist can confirm the diagnosis and rule out other conditions that may mimic the appearance of the papules. For severe and refractory pain, a specialist may recommend more invasive options, such as corticosteroid injections or, in rare instances, surgical removal. Consultation is also advised if the papules are accompanied by signs of a possible underlying connective tissue disorder, such as unusually flexible joints.